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Hey guys. Um we'll be starting shortly. We're waiting for a few more people to join. Can you hear me? Ok, so, hello everyone. Um This is, hi and thank you for joining us for the talk today um on capacity assessment and um sectioning. Uh we have doctor Nisha Patel here and I'd like to hand it over to her now. Ok. Um Hi guys. Can you hear me? Sorry. It's fast. I'm using metal. So I'm just gonna try and ch share my screen now. Yeah, we can hear, I can hear you. Ok? I can hear you guys as well. Don't worry. Um Let me see if I can share from the beginning. All right. Can you see my slides? Ok. Yeah. Yeah, it looks cool. So, um well, we're gonna try and run through capacity um a bit about cognitive um function um tests and also about sectioning. So, um as the team was saying, I'm n I'm one of the, well, I'm now working as an F three, so as a clinical education fellow. Um but in the past two years I've done and a lot of acute medicine, um not necessarily a psych job but I've been exposed to like having to go through um consenting capacity, sex assessments and sectioning. So hopefully you'll be able to run through some things that will be helpful for you guys um for um when you start as a junior doctor. So when we're talking about consenting, um do you, so, uh we need to consider when consent um is actually needed. Um So I am just going to um escape this screen slightly so I can see the comments as well. I apologize. Um One second, that's fine. Um So I wanted to be a bit more interactive, but I'll see if I can join on my phone. I just wanted to ask you guys when you think consent might be needed. Um You can put the answers in the comments if you don't necessarily want to speak up. Um I'm just going to join from my phone so I can see what you guys are commenting one second. OK. Um So I will, well, I will tell you so basically and in the medical context, um the times when we'll require consent will be things like um you know, um when um when we are considering um having a patient going for any treatment, investigation, examination, and it's basically a key element of patient care. Other times when we, when we might require consent will be um things like if um we're considering for like research or we need to use the patient's um notes for case studies and things like this, but in medical consent, it will be usually to do with treatment and investigation. Um What types of consent do you guys know about? What have you heard? What types of consent have you heard of? How can we consent our patients? Mhm. See. Can't really see the comments currently. So let me go back into the medical app. Are you guys? Oh, it's not letting me see anything. All right, I will, I wanted this to be a bit more interactive, but obviously, it's not wanting to do that. So I'm going to run through it and tell you. So the different types of consent we have are written verbal and, and implied. So for example, if patient holds their arm out for a BP reading or for um venue, then this would be an implied type of consent and considering when it's considered to be valid. So consent is considered to be valid when it's informed. So the patient understands the procedure, the risks, the benefits when it's voluntary. So without pressure or coercion and when the person consenting has capacity to make the decision. Um So the capacity part is what we're going to go into um a bit in a bit more detail through this um some well through this lecture. Um So, um but quickly, I just wanted to run through um consenting your patient. So um when you're thinking about consenting a patient, um ideally, that's a shared decision making between you and the patients. So ensuring the because the patient will be an expert of themselves and you should be an expert in the medicine side. You should ensure that you have understanding of the individual clinical context and ensure that you are qualified and confident and knowledgeable. So for example, you might be asked to consent a patient um for um some sort of procedure. So for example, for an acidic drain on the ward, um but necessarily you shouldn't um consent that patient unless you're confident um in, in um explaining the procedure. So like a registrar might ask you, can you please go consent this patient for such and such procedure, but if you're not confident in it and you can't explain all of the important parts. So of what the procedure can entails. So the risks and benefits you shouldn't necessarily be consenting them. Um And generally the parts of consent that we usually go through will be the indication and benefits. Um The, the key risks and the key um are the key benefits um Checking the patient's understanding and allowing time for them to um basically ask you any questions and sometimes providing some written information and then closing is to reassure that the patient um can change their mind and withdraw consent at any time. Um This is an example of a consent form that we do for patients that have capacity. So it's called a consent form one, they have slightly different ones for radiology, but probably we can do a different session that talks um directly about consent forms. And then the other type of consent form that we can do is for those that lack capacity. Um We, this is what we're gonna go into a bit more about considering whether or not a patient lacks capacity and whether or not they require this type of consent form, it's called a consent form for it's usually present on most wards. And um usually, um if the patient that capacity, you are doing the consent in their best interest. But on the form, it says that you should discuss with like a family member or sometimes they have this thing that's called a lasting power of attorney, which will go over. Um Basically means that they are able to um make decisions on behalf of the of the patient. So when we talk about capacity, the reason why it's important is because in the on the wards, we're all basically usually asked to um explain or um you know, go and decide whether or not a patient has capacity. It's not. So it's not always so easy because um like we like we see in the next slide capacity is quite fluctuant um and is um decision um dependent. So that's why um it's important that if you are consenting a patient, there should be no doubt about their mental capacity. If there is some sort of doubt. Then in that case, um you should um you should carry out a mental capacity assessment. So how do we assess the patient's capacity? Um Ideally, I wanted you guys to tell me, but I'm having a bit of issues seeing the comments one second. So usually there's four components of um of capacity that we usually go through. Um So um I will go through them with you and so um the patient must be able to understand the information. Um ok, now I can see they do apologize. So do you guys, so what are the four components? What are the key components of capacity? So there are 44 main components that we usually have to make sure if we tell the patient some sort of information, you want them to understand something. What are the um four components we usually need them to, to go through. You guys can write it in the comments if you don't wanna say it. I've got the first one up. So they need to understand the information. What else do they need to be able to do with the information that we tell them? Yeah, exactly. So they need to be able to understand the information, they need to be able to retain it, um weigh it up and communicate it. So what that basically means is when we see the patient understands the information, this means um they can understand the situation and the options, the options that are presented. So, um they need to understand maybe why they're being in hospital or they need to understand what the options might be when for managing an infection. If we're considering giving them IV antibiotics, they need to be able to retain information. So consider if they forget the conversation, conversation quickly or they become um distracted, um and they are unable to continue. Um So for example, this might be if they're on some sort of medication, if they're tired, if they've got a thought disorder, and in these cases, you may need to come back and conduct your assessment at another time. Um If, if you're considering memory issues, you might need to also do a cognitive function test, which we'll go over um a bit later in these slides and they need to be able to use the information. So weigh up the options and make a decision based on their reasoning. Um An important point is flawed logic doesn't mean that they lack capacity as long as the decision is supported by the patient's own reasoning. Um So you might, so for example, a common one would be like, um if, oh, I can't say that I don't want to say anything that's too controversial. But for example, if you've got a Jehovah's witness and they're against having a blood transfusion, you could argue from a medical perspective that that's um could be like flawed logic, but technically, it's based on beliefs. So not really flawed logic, but it supports the patient's own patients own reasoning. Although um from a medical perspective, we might not um agree with this and then they must be able to communicate the decision. So this could be in any format. So verbal, written, um with sign language or with gestures when you have gone through all these things, and you've assessed the capacity of your patient, make sure I've always, I always say to my students, make sure you document everything. So the indication for the assessment, the decision this relates to the date and time and who was present. This is because the capacity can fluctuate. So you need to know, make a note of when the decision needs to be next reviewed and if appropriate, the next of kin should be informed as well. Um And that's why sometimes complex cases they need to be discussed in um multidisciplinary meetings and with seniors and sometimes with a psychiatry in as well. This is an example of a mental capacity care plan um that might be present on your ward for some of the patients. So it just kind of runs through um whether or not there's any impairment to their capacity. Um And then based on that, um some of it guides you through the for questions that you need to ask about and then um also other things like um protective factors. So thinking about if there's a next of kin that you might need to speak to if they lack capacity and applying for a adults um authorization, which we will go through um in the next coming slides, this is um the Mental Capacity Act um and the key principles of this. So, um based on those four things that we said for capacity, that's for, that's so understanding, retaining way and communicating, that's what we need to do to assess their capacity. But when deciding whether or not the patient has capacity, the mental Capacity Act basically set out a standard that defines um you know how you're coming to the decision of whether or not your patient has capacity or not. So things like you need to make sure that you presume capacity um until proven otherwise, um you need to support the individual with making their own decisions. Um And then like we said, if the with flawed logic doesn't mean that the patient doesn't have capacity, um If the patient comes out to have uh to be lacking the incapacity decisions you've made in their best interest. And um you, if you're making a decision in the best interests of your patient, you need to use the least restrictive option. So the option that restricts the patient's um freedom to think or freedom um doesn't restrict the freedom more than is required. Um This is quite a busy slide, but basically, it's just to say to you that if a patient lacks cap, the patient might lack capacity and um they may let capacity due to various factors. So this might be due to an impairment of brain or mind. This might be um this might be permanent or like we say, progressive or it might be acute. So progressive impairment would be things like dementias, permanent impairment might be in traumatic brain injuries or temporary might be in cases where we have delirium or intoxication. And this is why the mental state can fluctuate and must be reassessed at various times. Um Capacity should always be discussed based on the decision. So it needs to be um like they might have capacity to decide what they want to eat for dinner, but they might not have capacity to decide whether or not they should be receiving IV antibiotics. That's what we mean by it being decision um specific and like we said before, um never assume that a patient lacks capacity because of their medical or psychiatric history, appearance behavior. Um and all patients are entitled to their own opinions. So, um for those patients that we think um might lack capacity or um might have some sort of progressive or permanent or temporary um fluctuation to their capacity. Um And we've done a capacity assessment for them and we're not quite sure, you know, what's the underlying pathology. Um We sometimes also do, also do other cognitive tests to kind of um see whether or not these might, they might um indicate what the baseline pathology is for them lacking capacity. So the image that we have up is a mini mental state exam. So there are a lot of tests that you can do for testing cognitive function. But I'm going to cover the two most common ones that I usually use on the ward. So the one that we usually do for progressive um decline in cognitive function. So if we think if we're suspecting whether they have a dementia or um if they've got a traumatic brain injury, for example, it's usually doing a um mini mental state exam. Um So you'll commonly find all of find these papers on the wards and it runs through um questions. So we have to determine whether the patient knows where they, who they are. So what their name is, um where they are in time, um and where they, where they are in space. So, um and then this um kind of questionnaire goes on to then ask them further questions, like getting them to follow instructions. Um So reading and um taking a paper and folding it and then the main one which is um usually asking them to write a sentence or to do the, the Pentagon type of diagram. Um And then we usually get a score from this. So, um usually scores um are uh thirties usually considered normal, 21 to 24 mild cognitive impairment and anything below that would be moderate and then severe. Um But if you don't have a mini mental status exam with you. Like I said, you need to just ask the patient three questions. Do they know what their name is? Um Do they know where they are right now? Um Do they know what date it is basically? So are they um rotated in time? Are they orientated in place? And are they orientated in person? And this usually covers um across both delirium and dementias then um for testing a um for testing an acute disruption um with their cognitive function, usually we do a CAM test. So a CAM test um is basically gonna be based on four criteria. So, um we need to consider um from collateral history um whether or not there's an acute onset or fluctuating fluctuating course to their cognitive, to their cognitive impairment um inattention. So, counting backwards from 20 um disorganized thinking and also altered levels of consciousness. So, if your patient shows um at least one, so, um if they show at least one of the um features of three and four and both one and two are present, then this usually means that they are delirious basically. Um because when we say delirium, like we said, it's an acute fluctuation in um cognitive deficit. Um The most easy task is sometimes it's difficult to assess all four of these things at once. So usually I usually go for point number two, which is um counting backwards from 20 point number one, you'll probably be able to, um, determine from the history anyway. And then, um, three and four, well, four, when you go and see a patient and you're doing your history, they should be somewhat alert and be able to engage with your questions. So that kind of already, um, answers that question and then disorganized thinking. Um, while you're asking your history questions, are they able to pay attention to what you're asking them about? So the only real special thing here would be getting them to count back Christmas 20 to see whether or not that can assess their delirium. Then um if the patient then lacks capacity, then there's a couple of things that we can consider. So first of all, um your nurses might put in a application for a dull so d provision of liberty. This basically um stops the patient from leaving hospital and then allows the nurses to give the patient like medication and treatment. Usually you as a doctor, don't fill out adults, but the nurses will do it for the patients. Um in Scotland, it's slightly different. They have this adults with Incapacity Act, which we're not gonna go over. Um And then on top of that, so the patient will have a dose in place that allows you to treat them in their best interest. Um And that also defines what they lack capacity for um you if you're making any decisions in the best interests of the patient there are a couple of things to consider. So first of all, discussing these decisions with the next of kin, um or ideally um a family member or a friend um who should be there. Um Also consulting in a multidisciplinary team. So you're not just making a decision yourself, we do consulting. It should be the whole team that's making this decision and some patients that lack capacity, um they already have something in place. Um that helps, that's basically supposed to be there to make decisions for them when they, when they lose capacity. So this is a lasting power of attorney for health and welfare. Similarly, you can have a lasting power of attorney for properties and finances, but this one doesn't have the same kind of um ability to influence healthcare related decision. So an LP is lasting power of attorney for health care and, and welfare and they usually will be like a nominated, usually a next of kin or a family friend and they will be able to make decisions for the patient on their behalf if they become too unwell. Um And usually you have to ask the next of kin to bring in this documentation for them. Um And then the other thing to consider is if they've got an advanced decision to refuse treatments, so you guys might have seen respect forms. Um So these are advanced decisions about refusing the decision, um refusing treatments. Um I think we, we probably will have to do a future talk to go into this a bit further. But basically, um what it basically means is when the patient had capacity, they outlined how much treatment they wanted um when they were approaching their end of life. And so now when they lose capacity, you kind of have a um list of how much treatment you can offer them, how far, whether or not they want to be resuscitated and how invasive they want their treatment to be. Um This is just a side about special circumstances so you can work against the wishes of a patient that has capacity if you think that they have an immediate threat to their own life. Um And then um if a patient, but this should be with a senior decision and if a patient is detained under a Mental Health Act capacity assessment should be carried out, being detained under the capacity. Um A patient could be detained under the Mental Health Act and still retained capacity, but we'll go over that in the next slide. Um And then there's also just a note about the court of protection that's involved in capacity decisions um for certain procedures as well. Um So I really terrible picture, but this is a picture of what the doll document kind of looks like. Um But you shouldn't be too, you should just know what a doll is and um that it allows you to treat the patient in your best interest, but you shouldn't really be having to fill it in. Usually these other members of the healthcare team that go ahead and fill this in. Um So I've got an example here. So, um we've got an 80 year old lady who's come in with a urinary tract infection and she's refusing to take antibiotics. The nurses are not clear why this is the case. Um She has no past medical history, no sign of delirium. Um And she has an interpreter. Um that said the last time she had antibiotics, she experienced severe diarrhea and she knows it's a different medication, but she's worried about this happening again. Um What do you guys think? Do you think this patient has the capacity to refuse antibiotic treatment? You can write it in your chart? Ok. I'm gonna give you one more minute to write if anyone wants to reply. Otherwise I'll go through the answer for this one. Yeah. Ok. Ok. Cool. Yeah. So we've got a couple of responses. So, um in this case, yeah. So in this case, the patient does have capacity. Exactly because um although the decision seems irrational, she's able to understand retain and has decided um upon the information that she's received and be, be able to communicate these wishes. So therefore they should be respected in this case. This is another case we've got. So you've got a 31 year old male who's presented to the emergency department after taking an overdose of paracetamol and alcohol. When you approach him on the bedside to gain consent for cannulation, he's able to open his eyes but it's too, too drowsy to engage in conversation. His wife tells you he's always been, he's been, always been afraid of needles. He has no power of attorney or no advanced directive. Do you think that this patient um, lacks the capacity to refuse IV cannulation? Um You can put your responses in the chart as well. Yeah, exactly. So at this time, this patient is quite intoxicated, so he's not able to do those things that we need him to do in able um in order to have capacity. So he's not able to understand, retain or communicate the information. Um Although he's got needle phobia, there's no advanced directive or no like legal documentation about him not wanting to have candidate in this instance. So because of his presentation, it is, it's in his best interest for him to receive and medications and fluids. But you might say that, you know, because he's common and acutely intoxicated um that you reassess his capacity regularly. Um as we expect that his cognition is gonna improve and obviously discuss with his next of kin and see what she thinks um regarding his um what his wishes might be as well. So that's capacity. So that's the mental capacity assessment separate to this. We have the Mental Health Act, which is for patients with a mental disorder to kind of put a ruler between mental capacity and mental health Act. When you actually go and practice in the hospitals, a lot of doctors and senior consultants will, it's not necessarily confused, but they will use certain elements of the Mental Health Act for patients that lack capacity. But there's a bit of a gray area about this and we'll go over the section exactly which one they tend to use. Um but necessarily when we talk about using a mental Health Act, it's supposed to be legal framework for informal or compulsory care of patients with mental health disorders. So those that have mental illnesses, personal disorders, um learning disorders, usually with aggressive behavior or serious i responsible conduct and with, um for example, those with disorders of sexual preference, um, the Mental Health Act excludes patients that are under the influence of alcohol and drugs. So we can't detain patients that are under the influence of alcohol and drugs under the Mental Health Act. And usually when we apply for a page for um sectioning a patient under the mental health Act, there are a couple of people that need to be involved. So, um the, the ones that will be on your side. So um on the er, unless you're in a psych job, the ones that will be on your side. So medical surgical side will be the responsible clinician. So you need to know the approved condition who has the overall responsibility of the patient care um the nearest relative um in the um um in the Mental Health Act list. And then usually when you, you've then made a, a application for section from the Psychiatry side, you will have a section 12 doctor. Um that could that usually the site consultant or specialty doctor that makes specific recommendations and an approved um mental health professional worker as well. Um Another thing about mental health that so it allows for patients to be um for them to be detained, um allows for treatment and discharge in aftercare. Um And usually it's used to hospitalize um patients that have a mental health um illness and they require assessment or treatment, they pose as a threat for themselves or others or um results in the patient not being able to consent as well. So, um when we, when, when we're going to detain a patient under the Mental Health Act, this basically means that the patient might still have, but overall they are refusing treatment that's required for usually for their psychiatric condition or they're refusing further assessment that's required for their psychiatric condition. And hence they can be detained into hospital against their wishes. These patients can necessarily still have capacity. I've got a table on it on the next side. But for this one, what we're going to do is we're just going to run through the main sections that you guys need to know. I think there's a lot of information on the online. But this is kind of like a picture that I found that kind of simplified it. So the main sections that you'll see are section 2345254 and then two holding sections which is section 135 and section 136. So first of all, section two, so usually we do section two first and that allows for um that allows for the patient to be to be brought in against their wishes for assessment. Um and this is usually for up to 28 days. This is usually done if you have two approved um two doctors and an approved mental health um practitioner and one of these doctors must be section 12 approved. Um then through under this section, you can treat the patient. But yeah, the treatment needs to be adding to um the ability to assess them. So section two detain them against their wishes to come into hospital for treatment. Then after this, these patients, this section two can't be, can't be extended. So usually then for these patients, we apply for a section three. So um this means that this is admission for treatment. So this can be up to six months um and allows um treatment to be given for usually. So it allows for treatment to be given against their wishes, but usually the treatment can be given for the first three months. And then after that, you need to apply for an extension before you can give the following three months um where the patient must be able to consent for treatment. But just remember, section two assessment, you've got 228 days, they still require further treatment. So you can apply for section three and this can be in place for up to six months. Um Section three again has to be done by, signed by two doctors and an approved mental health practitioner. Then um so this is usually the acute psych one, then you see a patient that's acutely unwell and is an emergency case. This is where section four comes in. So you have admission for assessment in the case of an emergency, usually for up to 72 hours. And the difference is that you only need one doctor to be able to do this. And um but it doesn't allow for treatment against the patient's will, it just allows for an emergency situation for the patient to be admitted for a further assessment in your practice, you'll probably see section 52 the most. So this is what we call is the doctor's holding power. So this is up to 72 hours. It's emergency holding power for current inpatients. So usually use for patients that are trying to leave the hospital and can be signed by the patient's responsible consultant or nominated deputy. Um And but it doesn't allow treatment. It basically holds, the patient says that they can't leave the hospital, but then they're gonna need to um have um a psych consult. Um If you then think that the patient lacks capacity and they require treatment, um It depends on what you're treating for. You probably need to give a dose. If it's medical treatment, if it's psychiatric treatment, you'll have to wait for a psych review and then section them under section three appropriately. Section 54 means is in another emergency holding for inpatients, but it's only for up to six hours and this is usually done by a registered mental health nurse. And again, doesn't allow for treatment and then um the two holding powers. So section 135 and section 136. So section 135 is um from a they're both police powers, but the difference is section 135 allows police to bring them in from a private place. Whereas section 136 is from a public place and then um for section 135, usually they say it says 36 hours, but usually one through five and 136 are both up to 24 hours that you can bring the patient in. I know it's a lot of information. So I'm just gonna go over it one more time. So two, you need to remember section two and section three together. So section two allows for um admission for assessment and you can treat under this and it needs to be two doctors and an approved mental health practitioner. Um and it's up to 28 days and then after the and it can't be extended if they need, it needs an extension or you need the patient to be in for longer, you should then do section three. So this is admission for treatment and this is up to six months and the same. So two doctors and an approved mental health practitioner. Um and um this one can be extended then in an emergency for admission for assessment but not for treatment. You can do a section four and that only needs one doctor and that can be done within 7 to 2 hours and then holding powers as in for inpatients, you've got section 52 and section 5452 is a doctor's holding power for up to 72 hours doesn't allow treatment, but it's for assessment. And then 54 is um another emergency holding for inpatients by a registered psych nurse doesn't allow treatment allows assessment. And then 135 and 136 are by the police to bring them to a safe place. So 135 is from a private place. 136 is from a public place to a place of safety. So a hospital and this is for 24 hours and to highlight again, can't do this if they're under the influence of alcohol or drugs. So this is just a table. So basically if you've got a patient. The main message I want to get to you is if you've got a patient and you think they need to be detained under the Mental Health Act, they're gonna be detained for. I see for you guys, you probably do a 52. So they'll be detained for assessment but um by the psychiatric team, but they can't be treated under that mental health act strictly. If you think that they um need treatment against their wishes for their medical decisions, then you'll have to do a dolls application and the dose application will allow you to treat them in their best interest. But that will, that will require like a capacity assessment to be done. So um for the mental health that the patient might have capacity to consent, but they're basically refusing care or treatment. Whereas mental um whereas if they under the mental Capacity Act, the patient lacks capacity to consent for care or treatment. Um mental health that doesn't include um treatment or physical illnesses unless they're direct consequence of the mental health disorder. But a mental but adults allows you to treat the physical illnesses of the patient against their um against their will. That's basically the main message on this slide. So this is a really busy side. But what I just want to summarize is as a doctor, you're gonna be doing five twos to be able to do a 522. You need to have full registration So all of us that are coming as IM GS should have full registration unless you're graduating from Poland or, or elsewhere. And you're coming in as a um with provisional registration as an F one and you need to be confident in your knowledge about five twos as well. Um Like we said, it allows for detention up to 72 hours after which you'll have to have an official assessment by an approved mental health um practitioner and a psych um consultant that's usually or a psych doctor that's got the section 12 approval. And then they will um they will then consider whether or not the patient needs to be detained under section two or three. You can't do a section 52 in an outpatient area. It's only in or in emergency department. It's only in an inpatient on the wards and um to apply for you for a section 52, there's this form which is a form H one that you usually need to apply for after you've um done the form to say that the patient needs to be detained under the mental Health app. You can just Google section 524 when it comes up. Um You should inform the patient of the reason why they're being detained and then also give it to the sister in charge and they will get the site managers. Um So senior nurses to come over and get it signed and it should allow for sufficient time for a full assessment by section two or five. And again, it doesn't allow for you to treat the patient against their will unless they are. Unless the physical illness that you're trying to treat is a direct consequence of the mental disorder. But that should probably have a psych opinion done first unless it's an emergency situation that we're dealing with. So I have a couple of questions to finish off. So, um we first of all have a 22 year old gentleman who has incoherent rambling of speech, an episode of psychosis two years ago, he lives with his parents and refuses to see a let him sick. Any mental health professionals or his GP his GP requests a mental health Act assessment. The GP and psychiatrist are coming for the assessment, which other person is required to be present during this assessment. Um So can you, if you guys can put the responses in the chat, please? What you guys think? Yeah, you can see a couple coming through now. Yeah, exactly. A so you know, when we were, when we were talking about it earlier, so we said um which other person is required the patient needs to have another approved mental health professional to be there? Um So they need to basically they need to have um you know, we were saying before, they need to have at least um two doctors and an approved mental health person that being, being present So, yeah, so let's move on to the second one. So you are a junior GP working in a busy surgery. I apologize. I haven't put ABCD E on this one. But um we'll get to that. So you've got a, you've got a patient. So the daughter of um, so the next kind of one of your elderly patients um of uh brings the elderly lady in the patient is agitated, she expresses bizarre delusions, paranoid beliefs, is shouting and is uring people in the surgery. She is uncooperative with consultation and is frequently pleading to go home. You and the daughter both feel that this patient needs um an urgent psychiatric opinion. So which of these sections um under which section of the Mental Health Act um could a GP detain a patient for emergency psychiatric assessment? Which section do you think um allows for emergency assessment if you guys get your own responses in the chat? Yeah, so we've got a couple of different opinions, right? So see. So um exactly. So we want the patient. So um you want, I see. So we, so it's only one doctor that's looking at the, at the issue, isn't it currently? So it's gonna be section four because you're gonna be um uh you're going to be admitting them for assessment of an emergency. Um And um in this case, like we said, um it's uh it's specifically only only the doctor that's there. Um That's, that's going to be able to give the um admission and it's an emergency situation. So this will be section four. We've got, well, I think this is the last case that I've got. So you are a junior doctor that's working in the emergency department. A 45 year old lady has, um, been brought in by the police under section 135. They have, um, had to apply for a warrant as part of the process. She is agitated and rambling religious phases, phrases and she's known to have severe depression. Um Which, what does the section 135 allow the police to do if you can put your response in the chat, please? Yeah. So some, so um some differing opinions, but it's the answer is gonna be d for this one because if you remember what we said, so if you're bringing a patient in from a public place, this is 136 and if you're bringing a patient in from a private place, um So their property, then this is 135. So it might be a finicky thing that comes up in terms of questions and things like that. Um I haven't really got an easy way of remembering of those, but you might be able to come up with some sort of pneumonic for remembering which one is, which, but 135 is um private and then 136 is from public. Ok, that's a whistle stop tour of Capacity assessments. Um The Mental Health Act, the Mental Capacity Act as well and a bit about cognitive functions as um cognitive assessments. Um If you guys have any questions, um feel free to put them in the chat now. But otherwise that's, that's it from me. Um Thank you for your time. I'm going to stop presenting um one second. Thank you so much. Um Doctor um Just a reminder uh for everyone that attended, um, you will receive a feedback form from us, so I'll send it. No, and then please fill it out so you can get your certificates. Yeah. Yeah, that will be all. Thank you everyone for joining.